Plantar Fasciitis: Evidence-Based Review of Treatment

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Original Articles

Plantar Fasciitis: Evidence-Based Review of Treatment Ana Lafuente Guijosa, Isabel O’Mullony Muñoz, Maruxa Escribá de La Fuente, and Paula Cura-Ituarte Unidad de Rehabilitación, Fundación Hospital Alcorcón, Alcorcón, Madrid, Spain

Objetive: To analyze the effectiveness of the

interventions in the management of plantar fasciitis. Material and method: The main medical and biomedical databases have been used: MedLine, Evidence Based Medicine, Cochrane Database of Systematic Review, Cochrane Register of Controlled Trials, EMBASE, and PEDRO (Physiotherapy Evidence Database). Metaanalysis, systematic reviews, reviews, and controlled or randomized clinical trials of interventions for heel pain have been selected. Results: After an updated review of the treatment of plantar fasciitis, we have found several therapy options to treat this problem, but their efficacy is variable, and none show strong evidence of benefit. The use of plantar insoles and stretching exercises focused on plantar fascia have demonstrated limited evidence of benefit. Corticosteroid injections and iontophoresis with steroids have also demonstrated evidence of benefit, although limited and during a short time. The rest of interventions have not demonstrated enough evidence of benefit. Conclusions: An evidence-based review of treatments of plantar fasciitis suggests that we must first recommend the use of conservative measures, easy to perform and of low cost, such as plantar soft insoles, plus specific stretching plantar fascia exercises. Limited evidence suggest that steroid injection or iontophoresis may be useful, but of transient effect, when conservative options fail. Key words: Plantar fasciitis. Heel pain. Painful heel

syndrome. Review. Treatment. Clinical trial.

Correspondence: Dra. A. Lafuente Guijosa. Baños de Montemayor, 5 portal 2-7.o A. 28005 Madrid. España. E-mail: [email protected]

Fascitis plantar: revisión del tratamiento basado en la evidencia Objetivos: Analizar la eficacia de los tratamientos utilizados en la fascitis plantar. Material y método: Se ha consultado los principales buscadores y bases de datos biomédicas: MEDLINE, Evidence Based Medicine, Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, EMBASE y PEDRO (Physiotherapy Evidence Database). Se seleccionó los estudios de mayor calidad científica: metaanálisis, revisiones sistemáticas, revisiones y ensayos clínicos controlados y/o aleatorizados de una o varias intervenciones para tratar el dolor plantar del talón. Resultados: Tras realizar una revisión bibliográfica actualizada sobre el tratamiento de las fascitis plantar, se encontró que existen múltiples opciones terapéuticas, pero su eficacia es variable y no hay evidencia fuerte del beneficio de ninguna modalidad de tratamiento. Únicamente se encontró limitada evidencia de beneficio con la utilización de taloneras blandas, junto con la realización de cinesiterapia, principalmente ejercicios específicos de estiramiento de la fascia plantar. Con las infiltraciones y la iontoforesis con corticoides también se ha demostrado beneficio, aunque limitado y a corto plazo. Con el resto de los tratamientos no se ha hallado suficiente evidencia de beneficio. Conclusiones: Según el análisis de la evidencia científica, ante una fascitis plantar debemos recomendar primero la utilización de medidas conservadoras, sencillas y de bajo coste, como taloneras blandas y ejercicios específicos de estiramiento de la fascia plantar. Si lo anterior no es eficaz, se puede administrar corticoides locales mediante infiltraciones o iontoforesis, aunque su efecto es transitorio. Palabras clave: Fascitis plantar. Dolor en la parte inferior del talón. Talalgia. Revisión. Tratamiento. Ensayo clínico.

Manuscript received December 28, 2006; accepted for publication March 22, 2007.

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Lafuente Guijosa A et al. Treatment of Plantar Fasciitis

Introduction Plantar fasciitis is a frequent problem of pain in the plantar region in adults. It is a long-term, self-limited process.1 Its prompt diagnosis and treatment increases the probability of success.2 The diagnosis is done through a clinical history and physical exploration. Its typical clinical presentation is pain on the plantar part of the foot and concretely, in the inferior part of the heel. It is usually more intense upon the first steps in the morning or after a period of physical inactivity, increases with prolonged standing or activities that require weight lifting. It is not frequently associated to paresthesia or nocturnal pain. Upon exploration, the patient feels pain when the interior part of the heel, the anteromedial calcaneus and/or along the plantar fascia is palpated. Pain increases on forced dorsiflexion of the foot and toes, with the extension of the knee when tensing the plantar aponeurosis and when walking on the tip of the toes. Simple foot x-rays are of little utility because no clinical-radiological correlation exists: up to 15%-20% of persons with a heel spur do not have plantar pain, and only 5% of patients with plantar pain have a heel spur visible on the x-ray.3 Ecography4 and magnetic resonance5 are useful tests to visualize changes in the morphology of the plantar fascia such as thickening; however, it is not necessary to carry out any complementary testing, unless another problem is suspected. Multiple treatment modalities are employed for plantar pain, from conservative measures—including massages, bandages, orthesis (foot and heel pads, nocturnal immobilization), therapeutic exercise, and physical therapy (laser, ultrasound, shock waves…)—to more aggressive steps, such as infiltrations and surgery. None of these treatments has proven to be effective, nor are there clinical practice guidelines and research on the subject is scarce. The objective of this review has been to determine the current state of the scientific evidence on the efficacy of different methods employed for the treatment of plantar fasciitis.

Material and Methods A review on the efficacy of the treatments employed for plantar fasciitis was carried out. To that end a bibliographic search of all of the articles published from January 1985 to December 2006 was carried out. The following biomedical search engines and databases were consulted: MEDLINE, Evidence Based Medicine, Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, EMBASE, and PEDRO (Physiotherapy Evidence Database). The search was limited to English language texts. The criteria for study selection were: a) type of study: metaanalysis, systematic review, reviews and/or clinical 160

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TABLE 1. PubMed and EMBASE Search Strategy Key Words

Results

PubMed 1. Plantar fasciitis

437

2. Heel pain

1056

3. Painful heel

787

4. One or 2, or 3

1383

5. Limits 4 to (Humans and English language and yr=“1985-2006”)

1020

6. Limits 5 to (All adult: 19+ years, clinical trial, review, randomized controlled trial)

136

7. Limits 7 to abstracts

131

EMBASE 1. Plantar fasciitis.mp

447

2. Heel pain.mp

451

3. Painful heel.mp

39

4. One or 2, or 3

775

5. Limit 4 to (human and English language and yr=“1985-2006”)

630

6. Clinical trial or review.mp

1 334 764

7. Five and 6

269

8. Limit 7 to (adult )

103

9. Limit 8 to abstracts PubMed and EMBASE Duplicates

95 35

controlled, and randomized trials; b) population under study: humans, adults, diagnosed with plantar fasciitis or pain in the plantar, or heel region; c) intervention: assigned to receive 1 or more interventions, or a comparative study to treat plantar pain; and d) that carried out at least 1 measurement of pain improvement. We used the following main key words for the search: “plantar fasciitis,” “heel pain,” and “painful heel,” and were combined with other search terms: review, clinical trial, therapy, treatment, etc. The search strategy employed in PubMed and EMBASE is shown in Table 1. In the efficacy analysis, special relevance was given to data proceeding from controlled and randomized clinical trials. The results of the studies have been classified (beneficial, non beneficial, reduced benefit) according to the levels of evidence normally employed by the Cochrane collaboration in its reviews6,7: a) strong evidence: concordant findings in multiple high-quality controlled and randomized trials; b) moderate evidence: findings limited to 1 high-quality randomized, controlled clinical

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PubMed 136

EMBASE 103

Duplicates 35 Total 204 Eliminated by Title 132 72 Without Abstracts 11 Abstracts Read 61 Eliminated Due to Lack of Criteria 41 Cochrane Databases

Article Total 20

6 Reviews (1 Systematic)

13 Clinical Trials

1 Observational Study

1 Systematic Review

2 Clinical Trials

Figure 1. Flow diagram of the studies.

trial, or concordant evidence from multiple low-quality trials; c) limited evidence: 1 randomized low-quality trial; d) no clear evidence: discordant or contradictory results in multiple clinical trials; and e) no evidence: no studies identified.

Hygiene Measures Relative rest avoiding mechanical overload and painaggravating activities: the use of soft-soled shoes, reducing body weight (obese and diabetic patients) applying ice after exercise. There is no scientific evidence of these measures.

Results The results of the search on PubMed, EMBASE, and Cochrane is presented in Figure 1. Two hundred and thirty-nine studies were located on PubMed and EMBASE, 35 of which were duplicates; of the other 204, 132 were excluded by title and 11 for lack of an abstract; of the remaining 61, 20 were selected: 13 trials with random allocation, 6 reviews, 1 systematic review and 1 observational prospective study. One systematic review and 2 clinical trials were located on the Cochrane collaboration database. Trials that included diagnostic and therapeutic methods seldom employed in clinical practice were excluded (bandaging, creams, botulinic toxin, etc). The characteristics of the studies are shown in Table 2. The different therapeutic options and scientific evidence of each one of them is presented below (Table 3).

Orthesis Multiple types of orthesis exist, but the one most commonly employed are nocturnal orthesis and heel pads. The objective of the orthesis is to prevent plantar flexion by maintaining the ankle in a neutral position and passively stretching the gastrocnemius/soleus muscles and the plantar fascia during nighttime. The efficacy of nocturnal orthesis is controversial, with significant improvements in up to 80% of patents with respect to a control group,8 without statistically significant differences in 2 clinical trials, one of them that compares it with another type of orthesis9 and another one compared with stretching exercises,10 or with 100% improvements when combining orthesis with soft heel pads, oral non-steroidal antinflammatory drugs (NSAID), and exercises.11 Is Spain this type of orthesis Reumatol Clin. 2007;3(4):159-65

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TABLE 2. Studies Included in Analysis* Authors

Type of Study

N

Intervention

Comparator

Results

Powell et al, 1998

CCRT

37 Nocturnal immobilization

Control

Significant improvement

Martin et al, 2001

CCRT

255 Nocturnal immobilization

Insoles

NS

Probe et al, 1999

CCRT

116 Nocturnal immobilization + ankle stretching exercise

Ankle stretching exercise

NS

Batt et al, 1996

CRT

34 Nocturnal immobilization + Ibruprofen + Significant improvement 100% ibuprofen + silicone heel pads silicone heel pads + of the nocturnal immobilization + stretching exercises stretching exercises group gastrocnemious/soleus gastrocnemious/soleus

Pfeffer et al, 1999

CCRT

Porter et al, 2002

236 Plantar fascial and Achilles tendon stretching exercises

Insoles (4 types) and the same exercises

All groups improved, with significant differences in the silicone gel and rubber heel pad group

CRT, 94 Continual Achilles tendon double blind exercises

Intermittent Achilles tendon exercises

NS, best result with intermittent exercise

diGiovanni et al, 2003

CCRT

Loaded Achilles tendon exercises

Best results with statistically significant differences with plantar fascia

diGiovanni et al, 2006

Observational, 101 Stretching exercises of prospective unloaded plantar fascia

Crawford, 1999

CCRT

91 Steroid infiltration + anesthetic

Infiltration of local anesthetic

Improvement with steroids in the short-term (1 month)

Black, 1996

CCRT

17 Steroid infiltration

Silicone heel pad

NS

Lynch, 1998

CCRT

85 Steroid infiltration

Silicone heel pad versus adhesive bandage

NS

Kriss, 1990

CCRT

80 Steroid infiltration and orthesis

Infiltration of steroids versus orthesis

Best result with steroid infiltration alone

Gudemman, 1997

CCRT, 40 Steroid Iontophoresis double blind

Placebo

At 2 weeks, significant improvement; at 6 weeks, NS

Crawford et al, 1996

PCCT

19 Ultrasounds

Placebo

Both decrease pain (30 and 25%); NS

Basford et al, 1998

PCCT

28 Laser

Placebo

NS

Caselli et al, 1997

PCCT

34 Magnetic insoles

Placebo

NS

101 Unloaded plantar fascia stretching exercises

Improvement of pain, 90%; without need for other treatments

*CRT indicates clinical randomized trial; CCRT, clinical controlled randomized trial; PCCT, placebo controlled clinical trial; NS, no statistical significant differences.

is seldom used, mainly because of the difficulty in patient compliance. In a recent systematic review12 limited evidence supporting the use of nocturnal orthesis in patients with pain longer than 6 months was found. Soft heel pads provide rest and reduce pressure on the heel by supporting the plantar arch. They are useful, comfortable and provide ample relief. No clinical trials on the effect of heel pads compared to placebo or controls. In a clinical trial13 in which steroid infiltration and the use of silicone heel pads was compared, no statistically significant difference was found between 162

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both treatments, but better results were obtained in the group using the heel pads. In the Cochrane12 review, limited evidence on the effect of prefabricated soft heel pads was found (better results were shown with silicone and gel pads), compared to other treatment modalities. Oral Non-Steroidal Anti-Inflammatory Drugs They provide temporal relief of inflammation and pain. No clinical trials comparing the use of oral NSAID by themselves have been found, only in combination with

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TABLE 3. Scientific Evidence on the Treatment of Plantar Fasciitis Intervention

Evidence

Steroid infiltration

Limited (short-term)

Steroid Iontophoresis

Limited (short-term)

Nocturnal orthesis

Limited

Soft heel pads

Limited

Plantar fascia stretching exercises

Limited

Laser

No evidence

Ultrasound

No evidence

Extracorporeal shock waves

No evidence

Electromagnetic-plated insoles

No evidence

Surgery

No evidence

other therapies such as orthesis and exercise,11 so no evidence for their isolated benefit12 exists. Exercise The majority of exercise programs include combinations of stretching exercises of the Achilles tendon and of the plantar fascia,3,14,15 some also include muscle strengthening exercises for the intrinsic muscles of the foot,16 because they can help in correcting functional factors, such as Achilles tendon thinning and foot muscle weakness. No clinical trial comparing stretching exercises and no treatment at all has been found. In 1 clinical trial14 that compared the practice of stretching exercises of the Achilles tendon and the plantar fascia with the performance of these same exercises plus several orthesis, no statistically significant differences were found between both groups after 8 weeks of treatment, though the exercise and heel pad group experimented a larger reduction in plantar pain. A clinical randomized, controlled trial did not find significant differences between carrying out Achilles tendon stretching exercises in a continuous manner and intermittently,17 but better results were obtained with intermittent practice. A clinical, prospective and randomized trial18 that compared 2 exercise programs, 1 with stretching of the Achilles tendon and the other with stretching of the plantar fascia (in patients using the same kind of soft heel pad and oral NSAID), observed that patients that had followed the specific plantar fascia stretching exercises (done on discharge) obtained better results, with statistically significant differences with respect to pain improvement (P=.02), limitation of activities and patient satisfaction in the group of Achilles tendon stretching exercises (done on discharge).

Stretching exercises of the plantar fascia are very simple: the patient is sitting while crossing the affected leg over the contralateral one and takes his toes over their base and flexes them dorsally. The patient must confirm that the stretching is correct by palpating the plantar fascia tension. Each stretching lasts for 10 seconds. A series of 10 repetitions 3 times a day is recommended. The first series must take place before setting foot on the floor upon waking up. Achilles tendon stretching exercises18 are done standing up: with the affected foot behind the healthy one and with the toes directed in a straight line to the anterior foots heel, the forward knee is flexed and the posterior (affected) leg is extended, without lifting the feet off the ground. Each stretching lasts for 10 seconds. A series of 10 repetitions is done 3 times a day. The first series must be done upon waking up. This group also showed improvement in pain, though partially, with statistically significant differences versus the plantar fascia-stretching group. These same authors later published19 the results of the same patients 2-year follow-up (both groups of treatment) who continued exercising the plantar fascia. More than 90% had a reduction in symptoms and over 75% did not merit any additional treatment. Steroid Infiltration Four clinical trials comparing steroid infiltration to the use of silicone filled heel pads,13 the injection of anesthetics,20 and different orthesis21,22 were found; their main finding was that steroid injections were useful in reducing plantar pain, but only in the short-term (1 month) and in a mild degree, so the evidence on their effectiveness was limited.12 A relationship between multiple injections and weakness, and rupture of the fascia with plantar fat atrophy have been described,20,23,24 so steroid injections are usually reserved for cases that are refractory to other therapies. Steroid Iontophoresis One randomized and placebo-controlled clinical trial25 demonstrated a significant efficacy of steroids applied through iontophoresis, but only in the short term (2-3 weeks). There were no significant differences at 6 weeks, leading to limited evidence on the efficacy of steroids administered through iontophoresis to reduce plantar pain.12 Ultrasound Only 1 small clinical trial controlled with placebo,26 that did not find significant differences between ultrasound Reumatol Clin. 2007;3(4):159-65

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Lafuente Guijosa A et al. Treatment of Plantar Fasciitis

treatment and placebo, was found, therefore there is no evidence that backs the claim the ultrasound improves the effectiveness of ultrasound.12 Laser Only 1 small clinical trial was found, finding no significant difference between laser treatment and placebo.27 Therefore, there is no evidence to back the effectiveness of laser.12 Electromagnetic-Plated Insoles One placebo-controlled clinical trial was found28 showing no significant difference; it even showed that persons without the electromagnetic insoles improved more than the ones treated with them. No evidence exists for their effectivity.12 Extracorporeal Low-Energy Shock Waves There are contradictory tests on the effectiveness of lowenergy extracorporeal shock-wave treatment, therefore evidence of its benefit is unclear.12,29 Surgery No randomized clinical trials were found regarding surgery for pain in plantar fascitis. The most common technique is partial fasciotomy: it can be done either through open or closed, endoscopic surgery, and both types of surgery, and equally efficacious.3 Neural decompression or burr resection can be performed in the same surgical event. Success rates of 70%-90%30-32 have been described and recovery varies from weeks to months. Complications such a fascial rupture, damage to the tibialis posterior nerve, flattening of the longitudinal arc, or heel hypoesthesia.

Discussion After analyzing the scientific evidence on different treatments employed for plantar fasciitis, no treatment option has shown strong evidence of benefit on which to base clinical practice (Table 3). Because this process can be long and incapacitating, one must start with simple measures and with a low probability of adverse events. Information on the norms that help reduce mechanical loads, such as weight loss, avoiding hard-soled shoes and limiting pain-inducing activities such as prolonged standing, can be provided. Other useful alternatives are 164

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the use of orthesis of the soft heel pad type and instructing the patient on a program of specific stretching exercises for the plantar fascia, as proposed by diGiovanni et al.18,19 The patient can carry out the exercise program in his house. They are carried out while sitting down, daily and at least during 8 weeks. If after these measures the patient continues to have pain or pain is very limiting, a local application of steroids or through injections or iontophoresis, knowing that even though they are useful, it is only in a transitory manner (improvement lasts approximately a month). There is no sufficient evidence of the benefit of other measures, such as the application of ultrasound, laser, electromagnetic-plated insoles, or surgery. Evidence on shock waves is still contradictory. Future research should be focused to carrying out clinical trials that include a larger number of patients, comparing different combinations and treatment algorithms, to analyze cost-effectiveness in the medium-to-long term.

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Lafuente Guijosa A et al. Treatment of Plantar Fasciitis

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26. Crawford F, Snaith M. How effective is ultrasound in the treatment of heel pain? Ann Rheum Dis. 1996;55:265-7. 27. Basford JR, Malanga GA, Krause DA, William PT, Harmsen MS. A randomised controlled evaluation of low-intensity laser therapy: Plantar fasciitis. Arch Phys Med Rehabil. 1998;79:249-54. 28. Caselli MA, Clark N, Lazarus S, Velez Z, Venegas L. Evaluation of magnetic foil and PPT Insoles in the treatment of heel pain. J Am Podiatr Med Assoc. 1997;87:11-6. 29. Thomson CE, Crawford F, Murray GD. The effectiveness of extra corporeal shock wave therapy for plantar heel pain: a systematic review and metaanalysis. BMC Musculoskelet Disord. 2005;22:19. 30. Leach RE, Seavey MS, Salter DK. Results of surgery in athletes with plantar fasciitis. Foot Ankle. 1986;7:156-61. 31. Daly PJ, Kitaoka HB, Chao YS. Plantar fasciotomy for intractable plantar fasciitis: clinical results and biomechanical evaluation. Foot Ankle. 1992;13:18895. 32. Benton-Weil W, Borreelli AH, Weil LS, Weil LS. Percutaneous plantar fasciotomy: a minimally invasive procedure for recalcitrant plantar fasciitis. J Foot Ankle Surg. 1998;37:269-72.

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